Abstract
Objective: To assess patient satisfaction, self-rated oral health and associated factors, including periodontal status and dental caries, among patients covered for dental insurance through a National Social Security Scheme in New Delhi, India. Method: A total of 1,498 patients participated in the study. Satisfaction levels and self-rated oral-health scores were measured using a questionnaire comprising 12 closed-ended questions. Clinical data were collected using the Community Periodontal Index (CPI) and the decayed, missing and filled teeth (DMFT) index. Regression analysis was conducted to evaluate factors associated with dental caries, periodontal status and self-rated oral health. Results: Areas of concern included poor cleanliness within the hospital, extensive delays for appointments, waiting time in hospital and inadequate interpersonal and communication skills among health-care professionals. Approximately 51% of the respondents rated their oral health as fair to poor. Younger age, no tobacco usage, good periodontal status and absence of dental caries were significantly associated with higher oral health satisfaction, with odds ratios of 3.94, 2.38, 2.58 and 2.09, respectively (P ≤ 0.001). Conclusion: The study indicates poor satisfaction levels with the current dental care system and a poor self-rated oral health status among the study population. Some specific areas of concern have been identified. These findings may facilitate restructuring of the existing dental services under the National Social Security Scheme towards creating a better patient care system.
Key words: Dental insurance, oral health, patient satisfaction, social security
Satisfaction with care is an important part of the health-care system that reflects the degree to which the caregivers acknowledge patients’ needs, earn their confidence and meet service standards. Assessment of patient satisfaction is as important and relevant as any other clinical health standard indicator for establishment of an effective health-care delivery system1. An advanced health-care management system requires health-care professionals to treat patients as valued customers. Despite involvement of distinct communities with varied interests in assessing customer satisfaction, the health-care fraternity has essentially failed to assess patient satisfaction levels, especially in developing countries such as India.
Health-care organisations, both public and private, need to identify their strengths and weaknesses. Both categories of organisations have ample reasons why they need to evaluate patient satisfaction. The evidence collected through evaluating patient satisfaction reflects the quality of care delivered and serves as a tool in decision-making. It serves to improve the accountability of the health-care providers. Patient satisfaction data can help to formulate health-care parameters, which in turn may be used for accrediting institutions. Such data may also provide an advantage in negotiating contracts2. However, the ability to identify and respond to unrealised issues before they become critical is the single most necessary reason for conducting patient-satisfaction surveys. Satisfaction must be articulated in the context of a spectrum of factors. Factors that may be used to determine satisfaction include accessibility, continuity of care, efficacy of care, finances, humaneness, pleasantness of the surroundings and quality/competence3.
The responsiveness of the health-care system refers to the manner and environment in which people are treated when they seek health care. Quantification of the patient experience makes it possible to capture the responsiveness of the health system4. The developing emphasis on patient experience, and interest in comparing people's satisfaction with the health-care system across countries and time periods, affirms the demand to outline the interrelationships among these various aspects. Research comparing global satisfaction ratings with patient experience reveals a robust association between the two5. Yet, the degree of accuracy by which patient experience can explain satisfaction with the health-care system is uncertain.
Self-rated oral health status is linked to the general state of health and to the functional capacity of the individual. Good oral health contributes independently towards long-term well-being and satisfaction6. Furthermore, self-rated oral health status has been established as a good predictor of morbidity and mortality7. Individuals reporting symptoms of poor oral health, dental and oral impairment, and disabilities have poorer self-reported oral-health status. Individuals who assess their oral health negatively have worse clinically identifiable conditions compared with those who rate their oral health positively6., 7., 8.. Extensive socio-economic differences have also been noted in self-rated health status; individuals with low socio-economic levels have poorer self-rated health than those from a higher socio-economic background9., 10.. Thus, it may be considered that self-rated oral health status is an expeditious indicator of the state of the population's oral health and associated factors and thereby contributes to health-care planning according to the population's needs11.
The Employee's State Insurance Act (ESI Act) is the first and only comprehensive welfare legislation for employees in independent India. The Employee's State Insurance Corporation (ESIC), established in 1948 under the Ministry of Labour & Employment, Government of India, is the largest welfare/social security organisation in Asia. The Employee's State Insurance Scheme, incorporated within the ESI Act, is an integrated and holistic social security scheme tailored to provide protection to employees in the organised sector, and their dependants, against varied contingencies, such as sickness or maternity, or death and disability resulting from an employment injury. Establishments or premises employing 10 or more individuals and offering a pay of not more than 15,000 Indian Rupees (Rs) per month (approximately ≤US$230) come under the purview of the Act for the multidimensional social security benefits12. A sweeping 35 million subjects (9% of the total population) are covered under the Act with contributions of 1.75% and 4.75% from employees and their employers, respectively, deductible as a fixed wage percentage. However, health-care assistance and benefits are administered according to individual requirements and not on the basis of the contributions made. The uniqueness of the social security scheme is that the insured subject and their dependants acquire health insurance, including dental insurance, for a single contribution13. The scheme works on the principle of pooling of resources, in which both the covered employee and employer contribute to the scheme, and the needy employee and his family avail benefits. The ESI scheme has the country's largest medical infrastructure facility under its umbrella. It is the only health insurance scheme that offers full medical care to workers and their dependants without any ceiling on individual expenditure. The outpatient, inpatient and specialist services are provided through a network of clinics known as ESI dispensaries and hospitals12.
Improving the quality of patient care is integral and indispensable to a socially responsible health-care system. The recent initiatives for improving the ESIC scheme include programmes for upgrading health-care infrastructure and delivery of quality health-care services. Health-care infrastructure and quality of health-care services can be successfully improved only if the existing shortcomings are identified based on the needs of the population. These are bound to be voiced as the subjective feelings of what people really want and perceive as being important. Despite the fact that insurance modifies the likelihood of utilisation of dental care, it remains uncertain how it influences the actual utility of such services, oral health status and, above all, patient satisfaction with the services provided. Furthermore, there are no existing data for patient satisfaction with the dental services provided to the insured population in India. The present study was carried out with these considerations in mind. The aim of this research was to assess patient satisfaction levels, self-rated oral-health status and associated factors, including periodontal status and dental caries among patients covered for dental insurance through a National Social Security Scheme in New Delhi, India.
Methods
Study design and subjects
The target population for this cross-sectional study was the insured patients attending only dental hospital in New Delhi that provides dental services under the National Social Security Scheme. The insured patients included employees and their dependants covered under the scheme. Health care for the insured and families is admissible from day 1 of entering into insurable employment. A total of 1,498 patients participated in the study from 1 October 2012 to 31 January 2013 (response rate = 82%).
Information on the demographic characteristics of the participants, along with the assessment of patient satisfaction, was collected by personal interviews and a questionnaire administered by the examiner. The dental team comprised two trained examiners who were assisted by a recording clerk.
Questionnaire
Satisfaction levels were broadly established within the three major dimensions of context, content (process) and outcome (results). Based on distinct scales available in the literature, further satisfaction subsets were developed within the three broader dimensions. The questionnaire comprised 12 closed-ended questions. The first two questions were to assess the duration that the employee had been under insurance coverage with the corporation and to determine the reason for the visit. The next nine questions were framed to establish the patients’ satisfaction with the services being provided, ranging from assistance received at reception, waiting time in the hospital, cleanliness of the hospital (including toilets), to behaviour of the chair-side dental assistant/technician and the dentist. The last question was to assess the self-rated oral health status among the study participants.
Clinical examination
Subjects were examined in a dental chair and data were compiled for periodontal status and dental caries. Dental examinations were conducted according to World Health Organization (WHO) recommendations14. A pilot study was conducted among 30 subjects to check the validity of the questionnaire and the feasibility of the study.
The Community Periodontal Index (CPI) was used to assess the periodontal health status utilising a mouth mirror and a CPI probe. The dentition is divided into six sextants for assessment of periodontal status through examination of the specific index teeth using a CPI probe. The probe is used for measuring pocket depths and detecting subgingival calculus. Each sextant is given a code: 0 for healthy tissues; 1 for bleeding on probing; 2 for calculus; 3 for pockets of ≤4–5 mm; and 4 for pockets of ≥6 mm. The CPI rating is based on the worst finding from each sextant14. In the present study, the WHO criteria were used for recording dentition status. A systematic approach was adopted for examination of dentition status, with the investigation advancing in a scientific manner from one tooth/tooth space to the adjoining tooth/tooth space. If permanent and primary teeth engaged the same tooth space then the status of the permanent tooth was noted. Decayed, missing and filled teeth counts were estimated using the DMFT index.
A 2-day training session was conducted for standardisation and calibration of the examiners. The kappa statistic was calculated and a score of 0.86 for interexaminer agreement was achieved. Intra-examiner agreement between 0.88 and 0.92 was attained by both examiners. Examination procedures were standardised for validity and reproducibility of data before and during the survey.
Ethical clearance was granted by the Institutional Ethics Committee of ESIC Dental College and Hospital, New Delhi. Written, informed consent from the study subjects was obtained before they were included in the survey. Research was conducted in full compliance with the World Medical Association Declaration of Helsinki. A pilot study was conducted to test the validity of the satisfaction questionnaire. Duplicate examinations were conducted systematically on approximately 10% (every 10th sample) of the subjects by both examiners throughout the survey and the kappa statistic was in the range of 0.86–0.90.
Statistical analysis
Data were collected, then entered into and analysed using SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) for Windows. Cronbach's alpha was used to evaluate the validity of the questionnaire. The chi-square test and the Mann–Whitney U-test were used to compare the two groups of categorical and quantitative variables. Multiple regression and binary logistic analyses were used for multivariable statistical analysis. The default enter method was used for both linear and binary logistic analyses. Regression analysis was performed to determine the factors associated with dental caries and periodontal status. DMFT values and periodontal status (CPI scores) were the dependent variables in the regression analysis. Logistic analysis was conducted to assess indicators associated with self-rated oral health status from among a group of independent variables comprising age, gender, duration of insurance protection, annual family income, literacy levels, dental-care utilisation, tobacco-related habits, dental caries and periodontal status. Data was dichotomised prior to entry in logistic analysis. The odds ratio was computed for the study variables with 95% confidence interval. Significance was set at ≤0.05.
Results
Overall, the sample comprised 1,498 participants; among these, 837 (55.9%) were male and 661 (44.1%) female. Significant gender and literacy level differences were observed among comparable age groups. Forty-eight (5.7%) male workers were illiterate compared with 59 (8.9%) female workers; these subjects had not received any formal education. The recorded annual family income among 715 (60.6%) male and 406 (61.5%) female participants was ≤2,000 US $ (Table 1).
Table 1.
Demographic characteristics of the study population
| Variable | Gender | P | |
|---|---|---|---|
| Male | Female | ||
| Age group (years) | |||
| 18–34 | 182 (21.7) | 126 (19) | 0.001 |
| 35–44 | 317 (37.9) | 221 (33.5) | |
| 45–59 | 208 (24.9) | 215 (32.5) | |
| ≥60 | 130 (15.5) | 99 (15) | |
| Total | 837 (100) | 661 (100) | 1,498 (100) |
| Literacy status | |||
| Illiterate | 48 (5.7) | 59 (8.9) | 0.001 |
| Completed middle school (6th Grade) | 174 (20.8) | 197 (29.8) | |
| Completed high school (12th Grade) | 419 (50.1) | 232 (35.1) | |
| Graduation and higher | 196 (23.4) | 173 (26.2) | |
| Total | 837 (100) | 661 (100) | |
| Annual family income levels (Rs)* | |||
| ≤60,000 | 271 (32.4) | 198 (30) | 0.068 |
| ≥60,000 to ≤120,000 (~1,000 to 2,000 US $) | 444 (28.2) | 208 (31.5) | |
| ≥120,000 (~2,000 US $) | 122 (39.4) | 255 (38.5) | |
| Total | 837 (100) | 661 (100) | |
Values are given as n (%).
Rs, Indian Rupee; US, United States.
1 US$ = ∼ Rs 65.
No significant gender differences were noted for the materials and methods used to clean teeth. Statistically significant gender differences were noted for frequency of cleaning teeth (P ≤ 0.05) and frequency of sugar consumption (P ≤ 0.05). Consumption of sugar three times a day or more between meals was noted among 704 (84.1%) male subjects and 527 (79.8%) female subjects, respectively (Table 2). Significant gender differences were reported for tobacco-related habits and utilisation of dental care. Tobacco consumption was reported in 629 (62.7%) male subjects and in none of the female subjects (P ≤ 0.001). A total of 452 (50.7%) male subjects and 397 (60%) female subjects reported having never visited a dentist (P < 0.05) (Table 2).
Table 2.
Oral health behavioural characteristics of the study population
| Oral health-related behavioural variables | Male n (%) | Female n (%) | P |
|---|---|---|---|
| Mode of cleaning teeth | |||
| Finger | 55 (6.5) | 49 (7.4) | 0.63 |
| Toothbrush | 782 (93.5) | 612 (92.6) | |
| Frequency of cleaning teeth | |||
| Once daily | 738 (89.8) | 546 (86.9) | 0.05 |
| ≥2 times a day | 99 (10.2) | 115 (13.1) | |
| Material used for cleaning teeth | |||
| Toothpaste | 802 (86.8) | 642 (89) | 0.31 |
| Toothpowder | 35 (13.2) | 19 (11) | |
| Between-meal sugar consumption | |||
| Once a day | 13 (1.56) | 21 (3.2) | 0.05 |
| Twice a day | 120 (14.3) | 113 (17) | |
| ≥3 times a day | 704 (84.1) | 527 (79.8) | |
| Tobacco-related habits | |||
| Absent | 208 (37.3) | 661 (100) | 0.001 |
| Present | 629 (62.7) | 0 (0) | |
| Utilisation of dental care | |||
| Never visited | 425 (50.7) | 397 (60) | 0.05 |
| Previously visited | 412 (49.3) | 264 (40) | |
Significant gender differences were noted within the age groups 18–34 years (P < 0.05), 35–44 years (P < 0.001), 45–59 years (P < 0.001) and ≥60 years (P < 0.001) for the highest CPI scores. The mean number of sextants with the highest CPI score of 4 was 2.02 ± 1.39 and 3.32 ± 3.12 among male and female study participants, respectively. Mean sextants with the highest CPI score of 4 were 3.58 ± 3.32 and 3.01 ± 2.38, respectively, for male and female subjects in the ≥60 years age group (Table 3). Significant differences were noted for mean DMFT among all four age groups (P < 0.001). Mean DMFT scores of 5.23 ± 3.63 and 4.36 ± 3.57 were noted among the male and female study participants, respectively (P < 0.001) (Table 3).
Table 3.
Age-wise distribution of periodontal status and dental caries
| Age group (years) | Gender | P | |
|---|---|---|---|
| Male | Female | ||
| Mean number of sextants with the highest CPI score of 4 | |||
| 18–34 | 1.69 ± 1.82 | 1.61 ± 1.56 | 0.05 |
| 35–44 | 2.22 ± 1.51 | 1.93 ± 1.72 | 0.001 |
| 45–59 | 3.02 ± 2.6 | 2.53 ± 2.43 | 0.001 |
| ≥60 | 3.58 ± 3.34 | 3.01 ± 2.38 | 0.001 |
| Total | 2.63 ± 2.31 | 2.27 ± 2.02 | 0.001 |
| Mean DMFT index | |||
| 18–34 | 2.08 ± 1.61 | 2.70 ± 2.34 | 0.001 |
| 35–44 | 4.46 ± 2.29 | 3.81 ± 2.21 | 0.001 |
| 45–59 | 5.81 ± 3.14 | 4.08 ± 3.81 | 0.001 |
| ≥60 | 8.58 ± 7.48 | 6.86 ± 5.92 | 0.001 |
| Total | 5.23 ± 3.63 | 4.36 ± 3.57 | 0.001 |
Values are given as mean ± standard deviation.
CPI, Community Periodontal Index; DMFT, decayed, missing and filled teeth.
Seven-hundred and ninety-five (53.2%) subjects had been insured under the social security scheme for fewer than 10 years. The prime reason for a visit to the dental hospital was toothache followed by appointments for scaling and cleaning, as reported by 729 (48.7%) and 260 (17.4%) study participants, respectively, with significant gender differences (P ≤ 0.001). Assistance received at the hospital reception was reported to be slow and unhelpful by 825 (55.1%) study participants. Appointments were scheduled at intervals of 1–2 months for 1,039 (69.4%) study subjects. Long waiting periods of 1–2 hours and >2 hours were reported by 628 (42%) and 728 (48.6%) of study participants, respectively. Cleanliness of the dental hospital was rated as fair to poor by 743 (49.6%) and 536 (35.8%) of study subjects, respectively. Cleanliness of the toilets in the dental hospital was rated as poor by 1,307 (87.2%) study subjects, with significant gender differences noted (P ≤ 0.001). Dental assistants and dentists, respectively, were rated as friendly and professional by only 349 (23.3%) and 734 (49%) of subjects. Satisfaction with the current dental visit was rated as good by 585 (39%) subjects and poor by 547 (36.5%) subjects. Self-rated oral health status was perceived as poor by 481 (32.1%) subjects and fair by 288 (19.2%) subjects, with significantly higher satisfaction ratings reported by female participants (P ≤ 0.001) (Table 4).
Table 4.
Assessment of patient satisfaction questionnaire in the study population
| Question | Options | Response | P | Total | |
|---|---|---|---|---|---|
| Male | Female | ||||
| Q1. For how many years have you been insured? | Fewer than 5 years | 326 (38.9) | 203 (30.7) | 0.58 | 529 (35.3) |
| Between 5 and 10 years | 154 (18.4) | 112 (16.9) | 266 (17.8) | ||
| Between 11 and 20 years | 176 (21) | 143 (21.7) | 319 (21.3) | ||
| More than 20 years | 181 (21.7) | 203 (30.7) | 384 (25.6) | ||
| Q2. What is the purpose of your visit to the dental hospital today? | General examination | 37 (4.4) | 68 (10.3) | 0.001 | 105 (7) |
| Toothache | 510 (60.9) | 219 (33.1) | 0.001 | 729 (48.7) | |
| Scaling and cleaning | 77 (9.2) | 183 (27.7) | 0.001 | 260 (17.4) | |
| Prosthesis | 82 (9.8) | 59 (8.9) | 0.41 | 141 (9.4) | |
| Follow up | 108 (12.9) | 114 (17.1) | 0.001 | 222 (14.8) | |
| Any other | 23 (2.8) | 18 (2.7) | 0.38 | 41 (2.7) | |
| Q3. When you arrived the assistance received from the reception? | Prompt and helpful | 63 (7.5) | 50 (7.6) | 0.11 | 113 (7.4) |
| Helpful after I asked | 198 (23.7) | 169 (25.6) | 367 (24.5) | ||
| Slow and unhelpful | 467 (55.8) | 358 (54.1) | 825 (55.1) | ||
| Rude | 109 (13) | 84 (12.7) | 193 (13) | ||
| Q4. When calling for an appointment, how long after was your appointment scheduled for? | Less than a week | 208 (25) | 189 (28.6) | 0.08 | 397 (26.5) |
| 1 month | 327 (39) | 207 (31.3) | 534 (35.6) | ||
| More than 1 month but less than 2 months | 268 (32) | 237 (35.9) | 505 (33.8) | ||
| More than 2 months | 34 (4) | 28 (4.2) | 62 (4.1) | ||
| Q5. How long do you usually wait when you have an appointment? | Less than 30 minutes | 8 (1) | 13 (2) | 0.37 | 21 (1.4) |
| 30–59 minutes | 78 (9.3) | 43 (6.5) | 121 (8) | ||
| 1–2 hours | 338 (40.4) | 290 (43.9) | 628 (42) | ||
| More than 2 hours | 413 (49.3) | 315 (47.7) | 728 (48.6) | ||
| Q6. How would you rate the cleanliness of the dental hospital? | Excellent | 11 (1.3) | 4 (0.6) | 0.001 | 15 (1) |
| Good | 133 (15.9) | 71 (10.7) | 204 (13.6) | ||
| Fair | 439 (52.5) | 304 (46) | 743 (49.6) | ||
| Poor | 254 (30.3) | 282 (42.7) | 536 (35.8) | ||
| Q7. How would you rate the cleanliness of the washroom of the dental hospital? | Excellent | 0 (–) | 0 (–) | 0.001 | 0 (–) |
| Good | 24 (15.9) | 9 (10.7) | 33 (2.2) | ||
| Fair | 109 (52.5) | 49 (46) | 158 (10.5) | ||
| Poor | 704 (30.3) | 603 (42.7) | 1307 (87.2) | ||
| Q8. How would you rate the waiting room of the dental hospital? | Excellent | 98 (11.7) | 33 (5) | 0.05 | 131 (8.7) |
| Good | 399 (47.7) | 341 (51.6) | 740 (49.3) | ||
| Fair | 232 (27.7) | 187 (28.3) | 419 (28) | ||
| Poor | 108 (12.9) | 100 (15.1) | 208 (13.8) | ||
| Q9. Which term best describes your chair side dental assistant/staff/technician? | Friendly and professional | 206 (24.7) | 143 (21.6) | 0.26 | 349 (23.3) |
| Non-professional | 241 (28.8) | 189 (28.6) | 430 (28.7) | ||
| Insensitive | 199 (23.7) | 173 (26.1) | 372 (24.8) | ||
| Rude | 191 (22.8) | 156 (23.6) | 347 (23.2) | ||
| Q10. Which term best describes your dentist? | Friendly and professional | 408 (48.8) | 326 (49.3) | 0.05 | 734 (49) |
| Non-professional | 103 (12.3) | 129 (19.6) | 232 (15.5) | ||
| Insensitive | 179 (21.3) | 152 (23) | 331 (22) | ||
| Rude | 147 (17.6) | 54 (8.1) | 201 (13.4) | ||
| Q11. How would you rate your satisfaction with your current dental visit? | Excellent | 67 (8) | 57 (8.6) | 0.24 | 124 (8.2) |
| Good | 321 (38.4) | 264 (40) | 585 (39) | ||
| Fair | 141 (16.8) | 101 (15.2) | 242 (16.3) | ||
| Poor | 308 (36.8) | 239 (36.2) | 547 (36.5) | ||
| Q12. How would you rate your oral health? | Excellent | 91 (10.9) | 163 (24.6) | 0.001 | 254 (17) |
| Good | 191 (22.8) | 284 (43) | 475 (31.7) | ||
| Fair | 209 (24.9) | 79 (12) | 288 (19.2) | ||
| Poor | 346 (41.3) | 135 (20.4) | 481 (32.1) | ||
Values are given as n (%).
Linear regression analysis was performed to analyse caries and periodontal status against independent variables, including age, gender, literacy levels, annual family income, duration of insurance, frequency of cleaning teeth, frequency of between-meal sugar consumption, utilisation of dental care and tobacco consumption. Dental caries (DMFT) and the periodontal status model accounted for 47% and 59% variance, respectively. In the DMFT model, age, literacy levels and utilisation of dental care contributed, respectively, towards 25%, 8% and 5% of the variance (P < 0.001) (Table 5). The major factors that contributed to poor periodontal health were age, male subjects and tobacco consumption, with 37%, 5% and 11% contribution in the variance (P < 0.001) (Table 5).
Table 5.
Multiple linear regression model for decayed, missing and filled teeth (DMFT) and periodontal status
| Model | R | R2 | Adjusted R2 | SE | R2 change | P value |
|---|---|---|---|---|---|---|
| Multiple linear regression model for DMFT (dependent variable) | ||||||
| 1 | 0.5* | 0.25 | 0.25 | 2.31 | 0.25 | 0.001 |
| 2 | 0.53† | 0.28 | 0.28 | 2.33 | 0.03 | 0.001 |
| 3 | 0.60‡ | 0.36 | 0.36 | 2.31 | 0.08 | 0.001 |
| 4 | 0.61§ | 0.37 | 0.37 | 2.33 | 0.01 | 0.05 |
| 5 | 0.62¶ | 0.38 | 0.38 | 2.33 | 0.01 | 0.05 |
| 6 | 0.63** | 0.39 | 0.39 | 2.33 | 0.01 | 0.05 |
| 7 | 0.65†† | 0.42 | 0.42 | 2.29 | 0.03 | 0.001 |
| 8 | 0.69‡‡ | 0.47 | 0.47 | 2.31 | 0.05 | 0.001 |
| Multiple linear regression model for periodontal status (dependent variable) | ||||||
| 1 | 0.61* | 0.37 | 0.37 | 1.46 | 0.37 | 0.001 |
| 2 | 0.65† | 0.42 | 0.42 | 1.43 | 0.05 | 0.001 |
| 3 | 0.66‡ | 0.44 | 0.44 | 1.47 | 0.02 | 0.001 |
| 4 | 0.66§ | 0.44 | 0.44 | 1.47 | 0.00 | – |
| 5 | 0.67¶ | 0.45 | 0.45 | 1.44 | 0.01 | 0.05 |
| 6 | 0.68** | 0.46 | 0.46 | 1.45 | 0.01 | 0.05 |
| 7 | 0.68†† | 0.46 | 0.46 | 1.45 | 0.00 | – |
| 8 | 0.70‡‡ | 0.49 | 0.49 | 1.44 | 0.02 | 0.001 |
| 9 | 0.78§§ | 0.60 | 0.60 | 1.43 | 0.11 | 0.001 |
Predictors: age.
Predictors: age, gender.
Predictors: age, gender, literacy levels.
Predictors: age, gender, literacy levels, annual family income.
Predictors: age, gender, literacy levels, annual family income, duration since insured.
Predictors: age, gender, literacy levels, annual family income, duration since insured, frequency of cleaning teeth.
Predictors: age, gender, literacy levels, annual family income, duration since insured, frequency of cleaning teeth, frequency of between-meal sugar consumption.
Predictors: age, gender, literacy levels, annual family income, duration since insured, frequency of cleaning teeth, frequency of between-meal sugar consumption, utilisation of dental care.
Predictors: age, gender, literacy levels, annual family income, duration since insured, frequency of cleaning teeth, frequency of between-meal sugar consumption, utilisation of dental care, tobacco consumption.
SE, standard error.
Logistic regression analysis was employed with independent variables such as age, gender, duration since insured, annual family income, literacy levels, utilisation of dental care, tobacco consumption, dental caries and periodontal status to assess their contribution towards satisfaction with oral health. The association between age ≤45 years and satisfaction with oral health was significant with an odds ratio (OR) of 3.94 (P ≤ 0.001). Higher literacy levels were significantly associated with self-rated oral health with an OR of 1.34 (P ≤ 0.001). Utilisation of dental care in the year was related to oral health satisfaction (OR = 1.47; P ≤ 0.001). Subjects not consuming tobacco and with no periodontal pockets reported better satisfaction with their oral health status with ORs of 2.38 (P ≤ 0.001) and 2.58 (P ≤ 0.001), respectively. Female participants and subjects with no dental caries had higher satisfaction levels with ORs of 1.52 (P ≤ 0.001) and 2.09 (P ≤ 0.001), respectively. Duration of insurance under the National Social Security Scheme and annual family income were not associated with self-rated oral health satisfaction (Table 6).
Table 6.
Logistic regression analysis for satisfaction with oral health as the dependent variable (satisfied vs. non-satisfied) and age, gender, duration since insured, annual family income, literacy status, utilisation of dental care, tobacco consumption, dental caries and periodontal status as independent variables
| Variables | B | SE B | P | OR (95% CI) |
|---|---|---|---|---|
| Age | 0.73 | 0.0029 | 0.001 | 3.94 (4.02–3.88) |
| Gender | 0.68 | 0.0021 | 0.001 | 1.52 (1.47–1.59) |
| Duration since insured | 0.55 | 0.0019 | 0.27 | 0.19 (0.12–1.26) |
| Annual family income | 0.51 | 0.0026 | 0.48 | 0.35 (0.26–1.41) |
| Literacy status | 0.58 | 0.0023 | 0.001 | 1.34 (1.26–1.40) |
| Utilisation of dental care | 0.63 | 0.0024 | 0.001 | 1.47 (1.41–1.54) |
| Tobacco consumption | 0.68 | 0.0031 | 0.001 | 2.38 (2.30–2.47) |
| Dental caries | 0.66 | 0.0029 | 0.001 | 2.09 (2.02–2.16) |
| Periodontal status | 0.71 | 0.0033 | 0.001 | 2.58 (2.51–2.65) |
Variables: age (18–44 years and ≥45 years); gender (male and female); duration since insured (≤10 years and >10 years); annual family income (≤120,000 and >120,000); literacy status (graduation and higher or lesser); utilisation of dental care (utilised in previous year and not utilised in previous year); tobacco consumption (consumed and never consumed); dental caries (absent and present); periodontal status [Community Periodontal Index (CPI) score ≤2 and ≥3].95% CI, 95% confidence interval; OR, odds ratio; SE, standard error.
Discussion
Consumer satisfaction has evolved to play an essential role in reforms related to the quality of health-care delivery. The current scenario of intense competition in the service industries has compelled health-care organisations to focus on patient satisfaction. The specific areas of concern in the present study that need to be addressed are the low satisfaction levels with the assistance received at the hospital reception (74.7%), delayed appointment scheduling of more than 1 month (37.9%), long waiting periods of more than 1 hour prior to appointments (88.6%), cleanliness of the dental hospital (35.8% rating it poor) and cleanliness of toilets (87.2% rating them poor).
A large percentage of study participants were dissatisfied with the chair-side dental assistant/staff/technician (76.7%), dentist (51%) and the overall dental visit experience (36.5%). Considerable disparity exists between a doctor–patient relationship and the relationship between a business and its customer. Confrontations are driven by the consumerist behaviour of patients. Health-care organisations are apprehensive regarding the negative incentives that the satisfaction scales may bring into clinical practice. Patients may ask for an investigation, referral or treatment, which might be unnecessary, demand a restoration when a root canal/extraction is necessary, or make an unwarranted demand for antibiotics. In such circumstances, the health-care provider would respond to the patient's requests compassionately with an approach that attends to their concern. A response that contradicts the patients’ demands raises the risk of patient dissatisfaction.
Self-rated oral health status is a useful indicator of people's oral health. In our study, 48.7% of individuals rated their oral health as excellent/good and 51.3% as fair to poor. In comparison, higher satisfaction scores of 74.3%, 76.3% and 83% were reported among studies conducted in Brazil (in 2012), South Africa (in 2012) and Australia (in 2014), respectively15., 16., 17.. An association between increasing age and lower satisfaction with oral health was noted with an OR of 3.94 (P ≤ 0.001) in our study, the results being similar to studies conducted in Brazil (in 2012), South Africa (in 2012), Australia (in 2014) and Nigeria (in 2014)15., 16., 17., 18.. Significantly higher self-rated oral health scores were noted among female participants in the present study (OR = 1.52; P ≤ 0.001). Similarly, female subjects in a representative sample of 2,907 South African adults reported a higher self-rated satisfaction score16. In lower socio-economic groups, being insured was associated with better self-rated oral health status, but no such association was observed among the higher income groups in a random sample of 3,000 adults, in Australia, who were between 30 and 60 years of age19. No association was observed between higher family incomes and self-rated oral health scores in studies conducted in Brazil (in 2012) and Sweden (in 2007), the results being similar to those reported in our study15., 20.. No association was observed between oral health satisfaction scores and duration of insurance in the present study, the findings being in contrast to a study conducted in Australia19.
Utilisation of dental care in the last year was related to higher oral health satisfaction scores in our study. A cohort study conducted in Sweden (in 2007) concluded that patients not utilising dental care in the previous year were more dissatisfied with the current visit21. Similarly, in a Brazilian study (in 2012), individuals who sought a dentist for check-ups and treatment in the last year were 68% and 78%, respectively, less likely to report poor self-rated oral health15.
In the present study, subjects with no tobacco-related habits, no periodontal pockets and no dental caries were more satisfied with oral health, with ORs of 2.38, 2.58 and 2.09, respectively (P ≤ 0.001). The prevalence of negatively self-rated oral health status was 40% higher among 11,874 adults with periodontal problems from 250 Brazilian cities22. However, another study conducted among the elderly in Brazil (in 2012) reflected no such association with indicators of clinical health15. Self-rated oral health scores were negatively influenced by higher DMFT scores in a Japanese adult population (in 2013)23. A higher association between self-rated oral health status and dental-specific factors were noted in our study, in contrast to findings from the National Survey of Adult Oral Health (2004–2006) in Australia17. Among the indigenous Australian population, risk indicators contributing to poor self-rated oral health status included sociodemographic factors, literacy levels, access to dental care and psychological distress24., 25..
The findings from a Tanzanian study among 516 patients randomly selected from five public dental clinics26 reflected a moderate level of patient satisfaction. The need to improve quality in health-care delivery is increasing. Health-care organisations and insurance companies are equally determined to define and measure quality of health care. Patient satisfaction remains central to quality in health-care delivery. However, further exploration is essential to identify elements that can improve satisfaction with the health-care system. Specifically, the present study may have the limitation that it has not considered deeper influences, such as patients’ knowledge levels and behavioural factors, to explore the unexplained variation in levels of satisfaction. A mechanism for documenting complaints needs to be established and regulated to enhance the quality of patient care. The results of this study will not only expedite alteration of the policies in the hospital concerned, but could also guide the ESI Corporation (Ministry of Labour & Employment) in improving the services provided throughout the country under the National Social Security Scheme.
Conclusion
The findings of the present study indicate poor satisfaction with the dental care offered. Areas of concern include maintenance of cleanliness within the hospital, timing of appointment schedules, long waiting periods during appointments and poor interpersonal and communication skills among health-care professionals.
Acknowledgements
The study was supported by ESIC Dental College & Hospital, Ministry of Labour and Employment, Govt of India – New Delhi.
Conflict of interest
None declared.
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